Scleral fixation of dislocated posterior chamber intraocular lenses: Temporary haptic externalization through a clear corneal incision

Influence of Sutureless Scleral Fixation Techniques With 3-Piece Intraocular Lenses on Dislocation Force

PURPOSE

To compare 4 different secondary intraocular lens (IOL) fixation techniques regarding the least required force to dislocate a scleral fixated 3-piece IOL in human corneoscleral donor tissue.

DESIGN

Experimental laboratory investigation.

METHODS

The least required dislocation force (LRDF) of 4 different secondary IOL fixation techniques, namely, the techniques using transscleral tunnels (TTs; as described by Scharioth), glued haptics (GHs; Agarwal), flanged haptics (FHs; Yamane), and bent haptic ends (BH; Behera/Bolz), were investigated using 40 three-piece IOLs (Sensar AR40) fixated to human scleral tissue. The main outcome of the study, dislocation force between different techniques, was measured with a tensiometer.

RESULTS

The force needed to dislocate the haptics was highest with the FH technique and was significantly higher than with all the other techniques (GH vs FH: -1.02±0.02 N, P < .001; TT vs FH: -1.08±0.21 N, P < .001; BH vs FH: -1.00±0.25 N, P = .044). There was no significant difference regarding the dislocation force between the other techniques: GH vs TT (-0.06±0.100 N, P = .988), GH vs BH (-0.02±0.03 N, P = .60), TT vs BH (-0.08±0.04 N, P > .99).

CONCLUSIONS

The FH technique as described by Yamane proved to be the strongest form of secondary IOL fixation regarding dislocation force in this in vitro study. The other fixation techniques showed significantly less resistance to axial traction.

In office management of optic capture of scleral fixated posterior chamber intraocular lenses

Introduction

Optic capture of sutured scleral fixated posterior chamber intraocular lenses (PC IOLs) is an occasional complication resulting in blurred vision and discomfort.

Methods

A retrospective study of the management of 18 eyes (3.6%) with optic capture out of 495 eyes with scleral fixated IOLs during the study period. 54 procedures were performed in the management of optic capture of sutured scleral fixated PC IOLs. An in-office technique was utilized to relieve the optic capture by repositioning the optic posterior to the iris. This technique was performed after topical anesthesia and topical 5% betadine with the patient stably positioned at the slit lamp. Using a 30-gauge needle, sometimes after a 15-degree paracentesis blade, the needle was advanced in a parallel plane above the iris until the tip reached the edge of the captured optic. The optic is engaged in the inferior periphery away from the central visual axis, and pushed gently posteriorly just enough to reposition the optic posterior to the iris. In some cases, pilocarpine 2% drops were utilized after the procedure to decrease the risk of recapture of the optic.

Results

All 54 procedures were successfully performed in the office without significant pain or discomfort. Vision before optic capture, during optic capture, and at the first office visit after optic capture were comparable. There were not any cases of endophthalmitis, hyphema, iris trauma, iris prolapse or keratitis. While eight patients only had one episode of optic capture, 10 patients had multiple episodes of optic capture, all managed with this in office procedure. Recurrent optic capture occurred more frequently in eyes with fixation at less than 2 mm from the limbus than eyes with scleral fixation at 2 mm from the limbus.

Conclusion

Reposition of the optic after pupillary capture of a scleral fixated PC IOL can be successfully performed in the office without discomfort or significant complications and is an alternative management option to a return to the operating room. This procedure may be especially important when there is poor access to the operating room or restricted access to the operating room as during the COVID19 pandemic.

Clinical outcomes of combined pars plana vitrectomy and scleral fixation of the intraocular lens with a suspension bridge method in eyes with aphakia or insufficient capsular support

Purpose

To describe a modified technique of scleral fixation for intraocular lens (IOL) implantation and report the clinical outcomes of combined pars plana vitrectomy and scleral IOL fixation using the suspension bridge method.

Methods

This retrospective case series included 57 eyes (56 patients) of aphakia or phakic and pseudophakic eyes with insufficient capsular support that underwent IOL implantation or dislocated IOL repositioning with scleral fixation using the ‘suspension bridge’ method by a single surgeon between 1 July 2010 and 1 March 2019. Preoperative status, changes in visual acuity, refractive outcomes as spherical equivalent and related complications were assessed with a minimum follow‐up of 3 months.

Results

The mean follow‐up period was 25.5 ± 25.4 months. Preoperative visual acuity (logarithm of the minimum angle of resolution) was 1.32 ± 0.68 (20/400 Snellen), and it significantly improved to 0.80 ± 0.53 (20/125), 0.59 ± 0.56 (20/80) and 0.24 ± 0.37 (20/35) at 1 week, 1 month and 3 months, respectively (p < 0.001). Postoperative complications included corneal wound dehiscence (n = 1), vitreous incarceration (n = 1), optic‐iris capture (n = 6) and cystoid macular oedema (n = 1). The above‐mentioned complications were successfully corrected with simple procedures. However, one case of IOL dislocation required reoperation.

Conclusion

The modified technique of the suspension bridge method precludes the need for a scleral flap, with the advantage of easy adjustment of the IOL position. It is a simple and feasible technique with good surgical results and low complication rates.

Long-Term Stability of Sutured Scleral Fixation of a Posterior Chamber Intraocular Lens With 10-0 Polypropylene for More Than 30 Years

Purpose:

We report the longest follow-up to our knowledge of stable scleral fixation of a posterior chamber intraocular lens (PC IOL) with 10-0 polypropylene sutures.

Methods:

A retrospective review is presented of a case with more than 30 years’ follow-up after performing sutured scleral fixation with 10-0 polypropylene suture using 2 sutures tied together under a scleral flap. One suture was a cow-hitch looped around the haptic, and the other suture was passed through the sclera to create the scleral fixation.

Results:

The scleral fixation with 10-0 polypropylene suture knots for both haptics of the PC IOL allowed central optic positioning with excellent vision for more than 30 years without suture breakage.

Conclusions:

Polypropylene sutures for scleral fixation of PC IOLs remained stable for more than 30 years with central positioning of the PC IOL, without exposure of the fixation suture knots through the conjunctiva, and without suture breakage.

Intrascleral 4-flanged technique for in-the-bag intraocular lens subluxation

PURPOSE

To present a series of cases in which the 4-flanged technique was used in the management of in-the-bag intraocular lens (IOL) subluxation.

SETTING

Shamir Medical Center, Israel.

DESIGN

Retrospective cohort analysis.

METHODS

Included were consecutive cases with secondary IOL subluxation that underwent scleral fixation with the 4-flanged technique using 6-0 polypropylene and low temperature cautery. Surgeries were performed during September 2019 to April 2020. Postoperative IOL angle tilt was evaluated using high-resolution ocular coherence tomography.

RESULTS

Eleven eyes of 11 patients were included. The mean age was 82.7 ± 5.5 years, and 60% were men. Pseudoexfoliation was noted in 82% of patients, and only 1 case was related to trauma. The mean corrected distance visual acuity (CDVA) postoperatively was within 1 line of the original presubluxation CDVA (0.55 ± 0.41 vs 0.54 ± 0.6 logMAR, P = .965). The mean postoperative IOL tilt was 5.78 ± 3.85 degrees. Surgery duration decreased from 70 ± 14 minutes to 39 ± 15 minutes (first to last operations). No intraoperative complications were reported. Postoperatively, transient intraocular pressure elevation, which resolved at 1 week, was recorded in 45% of cases. Cystoid macular edema, which resolved within a few months under topical treatment, was seen in 2 patients.

CONCLUSIONS

Among a cohort of patients with secondary in-the-bag IOL subluxation, the 4-flanged technique was safe and resulted in satisfactory visual outcomes and a stable IOL position, with a short learning curve.

Knot-free suture scleral fixation of dislocated intraocular lenses: clinical results of a novel surgical technique

PURPOSE

To describe and report surgical outcomes of a novel, knot-free technique to manage dislocated intraocular lenses (IOLs).

SETTING

Beyoglu Eye Education and Research Hospital, Istanbul, Turkey.

DESIGN

Retrospective observational clinical study.

METHODS

The files of 47 patients were retrospectively reviewed, and the patients who had a follow-up time of 6 months or more were included in this study. The surgery of every case was watched for the surgical complications and calculation of the surgical time. The postoperative complications and success rate were specifically tabulated.

RESULTS

Thirty-five eyes of 35 patients were included in this study (23 men, 12 women; mean age 63.1 ± 19.2 years). The mean follow-up time was 22.5 ± 9.9 months. The mean surgical time was 28.2 ± 6.8 minutes. Corrected distance visual acuity improved significantly after surgery (P = .001). Anatomic success rate was 97.1% after a single surgery. Most common complications included transient intraocular pressure (IOP) elevation (n = 2), persistent IOP elevation (n = 1), mild IOL tilt (n = 1), mild IOL decentration (n = 1), secondary IOL dislocation requiring intervention (n = 1), transient corneal edema (n = 1), and bullous keratopathy (n = 1).

DISCUSSION

Knot-free suture scleral fixation of dislocated IOLs was a minimally invasive approach for the management of dislocated IOLs and required only two 20-gauge corneal incisions without the need for scleral flaps or incisions. This technique had a low complication rate and delivered successful results in most cases.

Outcomes of a new suture technique for the treatment of dislocated intraocular lenses: locked loop on the haptic

PURPOSE

To evaluate surgical and refractive outcomes of a new sutured scleral fixation technique in the management of subluxated intraocular lenses (IOLs).

METHODS

Nineteen eyes treated with the new scleral fixation technique were included. The mean corrected distance visual acuity (CDVA), postoperative refraction error, mean endothelial cell count (ECC), and complications were recorded. All patients were evaluated immediately postoperatively, at 1 and 7 days, and then at 1, 3, and 6 months.

RESULTS

The mean duration of follow-up of the patients was 10 months (range, 6-15 months). The mean CDVA was 0.41 ± 0.1 logMAR (logarithm of minimum angle of resolution) preoperatively and was 0.08 ± 0.07 logMAR postoperatively. The mean astigmatism was - 2.22 ± 1.86 D preoperative and was - 0.86 ± 0.58 D postoperative. The mean preoperative and postoperative ECC was 2455 ± 288 and 2352 ± 288, respectively. One patient (5.26%) experienced vitreous hemorrhage, and two (10.52%) experienced intraocular pressure elevation. IOL tilt and decentralization, conjunctival erosion, and cystoid macular edema were not observed in any eyes during follow-up.

CONCLUSION

This new IOL repositioning technique can be applied in a short surgical time and provides a stable IOL centration on long-term follow-up.

Scleral fixation of hydrophobic acrylic intraocular lenses using a suture burial technique

The procedure involved an ab-externo scleral fixation technique using a double-armed 10-0 polypropylene suture with straight needles that require no scleral flaps. The IOLs are sutured to the sclera, the free suture ends are tied to the suture loops, and they are buried together under the sclera. Forty eyes of 37 patients were included. Postoperative complications are IOL capture in five eyes (12.5%), a significant IOL tilt in one eye (2.5%), recurrent UGH (uveitis-glaucoma-hyphema) syndrome in two eyes (5%), glaucoma in three eyes (7.5%), suture exposure in two eyes (5%) and IOL drop due to haptic breakage in one eye (2.5%). The technique can be effectively used for the refixation of dislocated hydrophobic acrylic IOLs by temporary haptic externalization through a corneal incision and for the treatment of aphakia with or without penetrating keratoplasty. Surgeons should be aware of the possibility of UGH syndrome due to IOL capture, especially in young eyes.

Scleral fixation of Carlevale intraocular lens: A new tool in correcting aphakia with no capsular support

PURPOSE

To report the clinical outcomes of the use of a novel specially designed scleral fixated intraocular lens, the Carlevale intraocular lens (carlevale IOL, Soleko, Italy) for the correction of aphakia in the absence of capsular support of variable etiology.

METHODS

This retrospective, non-comparative study included 169 eyes of 169 consecutive patients who underwent 3-port pars plana vitrectomy and scleral fixation on Carlevale IOL. Inclusion criteria were at least 6 months' follow-up period, patients > 18 years old who underwent vitrectomy and Carlevale IOL placement for aphakia and inadequate capsular support.

RESULTS

The median follow up period of 9 months (range 6-18 months). Mean post-operative BCVA at the last follow-up visit was 20/25 (0.09 ± 0.1 LogMAR), improving from a mean baseline BCVA of 20/80 (0.58 ± 0.49 LogMAR), a statistically significant change (p = 0.0001). Regarding the post-operative complications, a transient rise in the IOP was observed in 28 patients (16.5%) and mild vitreous hemorrhage was observed in the immediate post-operative period in eight eyes (4.7%) and it spontaneously resolved within 3 weeks. All patients demonstrated good IOL position at the end of the follow-up without IOL capture. None of the patients required re-operation.

CONLCUSION

The present study represents the largest to date in evaluating the use of carlevale IOL in patients with aphakia and inadequate capsular support. The technique is safe and provides excellent post-operative IOL fixation without IOL capture in any of the patients studied.

Influence of sclerotomy size on intraocular lens tilt after intrascleral intraocular lens fixation

PURPOSE

To determine whether differences in sclerotomy size during intrascleral intraocular lens (IOL) fixation influence IOL tilt and visual acuity after surgery.

SETTING

University of Fukui Hospital and Japanese Red Cross Fukui Hospital, Japan.

DESIGN

Retrospective case series.

METHODS

The study reviewed the records of patients who had intrascleral IOL fixation with transconjunctival 25-gauge pars plana vitrectomy and a follow-up longer than 6 months. The preoperative and postoperative visual outcomes, degree of IOL tilt, and intraoperative and postoperative complications were statistically compared between the sclerotomy groups.

RESULTS

The study included 65 eyes (60 patients). Postoperatively, the maximum degree of IOL tilt was significantly smaller in the 24-gauge sclerotomy group than in the 30-gauge sclerotomy group (P = .003). The degree of IOL tilt was significantly correlated with the amount of postoperative IOL astigmatism (total astigmatism - corneal astigmatism) (P = .0001, R² = 0.23). There were no statistically significant differences in the preoperative or postoperative corrected distance visual acuity (CDVA) or the complication rate between the sclerotomy groups.

CONCLUSION

A smaller sclerotomy for intrascleral IOL fixation was associated with greater IOL tilt and IOL astigmatism after surgery; however, this did not clinically or significantly affect the postoperative CDVA.

Modified Cow-Hitch Suture for Repositioning of Subluxated Scleral-Fixated Rigid Intraocular Lens

BACKGROUND AND OBJECTIVE

To describe a new technique for repositioning a subluxated scleral-fixated rigid intraocular lens (IOL).

PATIENTS AND METHODS

The authors present a modified intraocular threading technique to tie a cow-hitch knot around the eyelet on the dislocated haptic of a scleral-fixated rigid IOL. This technique uses three small corneal incisions to eliminate the need for IOL externalization and minimized the size and number of wounds.

RESULTS

Three consecutive cases of subluxated haptics in two patients underwent this procedure. Postoperative IOL centration and alignment were satisfactory without tilt. No surgical-related complication was observed 1 year after surgery.

CONCLUSION

A rigid IOL could be repositioned to a desired axis and centration via this modified cow-hitch technique, with better IOL support as compared with a single tie. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:179-182.].

Modified sewing machine technique for iridodialysis repair, intraocular lens relocation, iris coloboma repair, Cionni ring fixation, and scleral-fixated intraocular lens

The purpose of this study is to report the modification of sewing machine technique for iris dialysis repair (MSMT) and its usefulness in managing other conditions such as intraocular lens (IOL) subluxation, iris coloboma, Cionni ring for zonular dialysis, and for scleral-fixated IOL. MSMT was based on sewing machine principle using a prethreaded 26G/30G needle with prolene suture for minimally invasive iris dialysis repair in a closed chamber manner. So far, eight patients (trauma - 3, surgical complication - 5) underwent this procedure. This technique is further modified to extend its use for IOL relocation - 2, iris coloboma repair - 3, and Cionni ring fixation for zonular dialysis - 2, SFIOL - 5 patients. All 20 patients had good visual recovery and cosmetic outcome with minimal morbidity. To conclude, MSMT offers cost -effective, minimally invasive, easy to learn procedure with a potential to tackle several problems related with cataract surgery and iris defects, which even an average cataract surgeon can learn to perform when required. Further comparative studies with conventional techniques with large sample size are required to standardize this procedure.

Long-term Outcome of Pars Plana Vitrectomy and Sutured Scleral-Fixated Posterior Chamber Intraocular Lens Implantation or Repositioning

PURPOSE

To assess the long-term stability of sutured scleral-fixated posterior chamber intraocular lenses (PCIOLs) performed in combination with pars plana vitrectomy.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

Retrospective single-surgeon study of 118 eyes of 111 patients seen at Retina Consultants of Hawaii, who underwent sutured scleral fixation of at least 1 haptic of a posterior chamber intraocular lens with 10-0 polypropylene combined with a pars plana vitrectomy. The fixation knot-tying technique required 2 separate 10-0 polypropylene sutures tied into 1 combined knot-1 suture closed the fixation sclerotomy and created the scleral fixation, and 1 suture looped together around the haptic of the PCIOL, securing the haptic to the scleral fixation site. The primary outcomes were position of the PCIOL at last follow-up, dislocation of either 1 or both haptics of the PCIOL, and breakage of the 10-0 polypropylene fixation suture.

RESULTS

PCIOLs remained well stabilized and positioned at last follow-up in 116 of 118 eyes (98.3%), with a mean follow-up of 6.0 years. The maximum stable follow-up with 2 intact fixation sutures was 24.75 years. There were 4 cases of redislocation (3.4%), but 2 cases were owing to unstable residual capsular support. There was 1 case of suture breakage in 214 fixation sutures (0.47%) and 1 case of haptic breakage.

CONCLUSIONS

Scleral fixation sutures with 10-0 polypropylene provide excellent long-term fixation of PCIOLs, with a less than 0.5% incidence of suture breakage and documented suture stability for up to 24+ years.

Surgical refixation of posteriorly dislocated intraocular lens with scleral-tuck technique

Purpose:

To report the outcomes of surgical refixation of posteriorly dislocated intraocular lens (IOL) using scleral-tuck method, and to compare the “scleral groove” and the “scleral flap” techniques used.

Study Design:

Single-center, retrospective, interventional, comparative study.

Methods:

Medical records of patients undergoing closed globe scleral refixation of posteriorly dislocated posterior chamber IOL (PCIOLs) by scleral-tuck method using two different techniques (”scleral groove” vs. “scleral flap” technique) were reviewed. This approach involved retrieving the dislocated PCIOL, externalizing the haptics through 2 sclerotomies created in paralimbal lamellar scleral grooves, or under lamellar scleral flaps and tucking the haptics into limbus-parallel scleral tunnels. No specific haptic architecture, haptic suturing, or large incisions were needed. Main outcome measures included best-corrected visual acuity (BCVA), final mean refractive error, and intra- and post-operative complications.

Results:

Thirteen eyes of 13 patients (scleral groove, n = 6; scleral flap, n = 7 eyes) with a mean follow-up of 20.6 months were included. BCVA in all eyes was maintained or improved postoperatively, with three eyes (23%) showing ≥2 line improvement. Median astigmatic error at 6-week follow-up was −1.25 D cylinder (range: −0.5 D–−2.0 D) which remained stable till final follow-up. All IOLs remained stable and well centered. None of the eyes had a recurrent dislocation, retinal detachment, endophthalmitis, or glaucoma. Both techniques were comparable in terms of postoperative BCVA, and refraction.

Conclusion:

Intrascleral haptic fixation by scleral-tuck method is reliable and effective for secure IOL refixation of posteriorly dislocated IOLs, providing good IOL centration and stability with minimal surgically-induced astigmatism. Both techniques (scleral groove and scleral flap) appear to have similar outcomes in the short term.

Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique

PURPOSE

To report the clinical outcomes of a new technique for transconjunctival intrascleral fixation of an intraocular lens (IOL).

DESIGN

Prospective, noncomparative, interventional case series.

PARTICIPANTS

One hundred eyes of 97 consecutive patients with aphakia, dislocated IOL, or subluxated crystalline lens who underwent posterior chamber sutureless implantation of an IOL were studied.

METHODS

Two angled incisions parallel to the limbus were made by 30-gauge thin-wall needles. Haptics of an IOL were externalized with the needles and cauterized to make a flange of the haptics. The flange of the haptics were pushed back and fixed into the scleral tunnels.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (VA), corneal endothelial cell density, IOL tilt, and complications were determined.

RESULTS

The IOLs were fixed with exact centration and axial stability. The mean preoperative best-corrected VA was 0.25 logarithm of the minimum angle of resolution (logMAR) units; after surgery, it improved significantly to 0.11 logMAR, 0.09 logMAR, 0.12 logMAR, and 0.04 logMAR at 6, 12, 24, and 36 months, respectively (P < 0.01, P < 0.01, P = 0.03, and P = 0.10, respectively). The mean corneal endothelial cell density decreased from 2341 cells/mm² before surgery to 2313 cells/mm², 2240 cells/mm², 2189 cells/mm², and 2244 cells/mm² at 6, 12, 24, and 36 months, respectively (P < 0.01, P < 0.01, P < 0.01, and P = 0.17, respectively). The mean IOL tilt was 3.4°±2.5°. The postoperative complications included iris capture by the IOL in 8 eyes (8%), vitreous hemorrhage in 5 eyes (5%), and cystoid macular edema in 1 eye (1%). There were no incidents of postoperative retinal detachment, endophthalmitis, or IOL dislocation.

CONCLUSIONS

We have developed a new technique for intrascleral IOL fixation. The flanged IOL fixation technique is a simple and minimally invasive method for achieving good IOL fixation with firm haptic fixation.

27-GAUGE NEEDLE-ASSISTED TECHNIQUE FOR REPOSITIONING A DISLOCATED INTRAOCULAR LENS

BACKGROUND

Several techniques for the reposition of a posterior chamber intraocular lens (IOL) posterior dislocating into the vitreous cavity have been developed. However, most of these methods are complicated or include externalizing part of the IOL from a corneal or scleral wound. We here describe a 27-gauge needle-assisted technique for management of a dislocated posterior chamber IOL.

METHODS

This is a retrospective, noncomparative, interventional case series that discusses the results of 27-gauge needle-assisted reposition of the posterior chamber IOL with transscleral sulcus fixation in 5 consecutive cases with an IOL dislocated into vitreous cavity. These patients underwent IOL reposition with the above-mentioned technique between April 2013 and October 2014 and were followed up for at least two months thereafter.

RESULTS

The IOLs of the five cases were stable with proper centrations. The postoperative best-corrected visual acuity ranged from 20/30 to 20/20.

CONCLUSION

The technique of 27-gauge needle-assisted reposition of the posterior chamber IOL with transscleral fixation is effective for reposition of a dislocated IOL. This technique provides good IOL fixation without creating a large corneal wound or scleral flap.

Ab-interno scleral suture loop fixation with cow-hitch knot in posterior chamber intraocular lens decentration

Aim of Study:

To describe a simplified ab-interno cow-hitch suture fixation technique for repositioning decentered posterior chamber intraocular lens (PC IOL).

Materials and Methods:

Two cases are presented with the surgical correction of decentered and subluxated IOL. Ab-interno scleral suture fixation technique with hitch-cow knot in the eye was performed with a ciliary sulcus guide instrument and 1 year follow-up was completed.

Results:

Both of the patients had well centered lenses postoperatively. Corrected distant and near visual acuities of the patients were improved. There was no significant postoperative complication. In the follow-up period of 1 year, no evidence of suture erosion was found.

Conclusions:

Ab-interno scleral suture loop fixation with hitch-cow knot in the eye was effective in repositioning decentered or subluxated PC IOLs with excellent postoperative centered lenses and visual outcomes.

A classification system of intraocular lens dislocation sites under operating microscopy, and the surgical techniques and outcomes of exchange surgery

Purpose

The aim of this study was to examine the recent status of intraocular lens (IOL) dislocation according to a classification system based on vertical dislocation position, as well as the surgical techniques and outcomes of IOL exchange surgery.

Methods

The medical records of 230 eyes from 214 consecutive patients who experienced IOL dislocation and underwent exchange surgery between 2006 and 2014 were reviewed. Vertical dislocation sites observed preoperatively under operating microscopy were examined, along with the surgical techniques and outcomes of IOL exchange.

Results

Dislocation sites included (1) the anterior chamber (12.2 %), (2) pseudophakodonesis (19.1 %), (3) the anterior vitreous cavity (47.4 %), (4) trap door-like dislocation (dangling in the peripheral vitreous cavity; 16.1 %), and (5) the retinal surface (5.2 %). The IOL retained in the anterior segment was moved onto the iris by pulling it up through the limbal side ports with an anterior vitrectomy (67.8 %), or by pushing it up from the pars plana with an anterior vitrectomy (26.5 %), while the IOL dropped on the retina was lifting it up from the retina after pars plana vitrectomy (5.7 %). Mean uncorrected and distance-corrected visual acuity significantly improved postoperatively (p < 0.0001). Major complications included a marked elevation in intraocular pressure (7.8 %), pupillary capture (6.5 %), and vitreous hemorrhage (2.6 %).

Conclusions

Based on the classification system, approximately 95 % of dislocated IOLs were retained in the anterior segment, and these IOLs were exchanged using an anterior approach through limbal incisions with an anterior vitrectomy. Visual acuity improved significantly, and serious complications were uncommon, probably because the IOL exchange techniques were standardized and simplified without pars plana vitrectomy.

Scleral fixation technique using a hydrophobic foldable intraocular lens with ring-shaped connecting bridges

We introduce a new method of scleral fixation using a hydrophobic foldable intraocular lens (IOL) with ring-shaped connecting bridges. A double-armed 10-0 polypropylene suturing needle is inserted using the routine ab externo technique. The midportion of the thread is pulled out through a main wound and cut. Using another 10-0 polypropylene needle, the IOL is sutured at both inner ring-shaped connecting bridges (inner shorter rim). The ring-shaped connecting-bridges IOL was carefully injected using the IOL cartridge with gentle pulling out of the thread. The externalized sutures were tied at the corresponding sites. All ties between 2 cut threads were performed using a European death knot. A scleral fixation outcome with the ring-shaped connecting-bridges IOL was similar to a poly(methyl methacrylate) IOL outcome; however, the surgeon should consider the possibility of a postoperative myopic shift.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Haptic breakage after transscleral fixation of a single-piece acrylic intraocular lens

PURPOSE

To report the case of a patient with a damaged haptic of an acrylic intraocular lens (IOL) after transscleral IOL fixation.

METHODS

This is a retrospective and descriptive case report.

RESULTS

A 40-year-old man presented with sudden visual loss in the left eye. He had undergone phacoemulsification/aspiration and IOL implantation 3 years previously and IOL repositioning with transscleral fixation 2 years before the initial visit. His visual acuity was 0.3 in the left eye due to corneal edema caused by a foreign body, i.e., the severed haptic tip of the single-piece acrylic IOL, which was surgically removed. The IOL itself was tilted and therefore explanted. The surface of the tip of the haptic suggested that the monofilament suture thread had exerted continuous force across the haptic.

CONCLUSIONS

The haptics of acrylic IOLs can be damaged after transscleral fixation.

Visual outcome and complications in Ab-externo scleral fixation IOL in aphakia in pediatric age group

Objective: To assess the visual outcome and complications in patients after Ab-externo scleral fixation of intraocular lens in pediatric age group (15 years or less).

Methods: This quasi experimental study was conducted at Isra Postgraduate Institute of Ophthalmology, Al-Ibrahim Eye Hospital, Karachi, from January 2012 to December 2012. All cases included were worked up according to the protocol. All patients underwent Ab-externo scleral fixation of IOL under general anesthesia. Patients were followed up at 1^stday, 1^stweek, 1^stmonth, 2^ndmonth and 3^rdmonth. Complete eye examination including best-corrected visual acuity and complications were noted on each visit.

Results: Thirty patients were included in the study, with mean age of 8.6 years (±3.93569). Most of the patients, 20 (66.7%), had visual acuities of 6/18 or better. No complication was seen in 18 (60%) of the patients intra operatively while soft eye was observed in 7 (23.3%) of the patients. Another complication noted was vitreous hemorrhage, which was seen in 5 (16.7%) patients. Most common post-operative complication was Uveitis followed by astigmatism. Lens dislocation and iris abnormalities were seen in only one patient. Most of the patients showed significant visual improvement after surgery.

Conclusion: Ab-externo scleral fixation of an IOL was found to be safe and showed favorable postoperative results with fewer complications.

Sutureless 27-gauge needle-guided intrascleral intraocular lens implantation with lamellar scleral dissection

PURPOSE

To report a new technique for performing sutureless intrascleral fixation of a posterior chamber intraocular lens (IOL).

DESIGN

Prospective, noncomparative, interventional case series on the results of sutureless intrascleral fixation of a posterior chamber IOL.

PARTICIPANTS

Thirty-five eyes of 34 consecutive patients with aphakia, dislocated IOL, or subluxated crystalline lens who underwent posterior chamber sutureless implantation of an IOL were studied.

METHODS

The haptics of the IOL were externalized with a 27-gauge needle passed through the ciliary sulcus using the double needle technique. The haptics were fixed in a scleral tunnel made by lamellar scleral dissection. The postoperative tilt of the IOL was measured by swept source optical coherence tomography.

MAIN OUTCOME MEASURES

The best-corrected visual acuity (BCVA), corneal endothelial cell density, IOL tilt, and complications were determined.

RESULTS

The IOLs were fixed with exact centration and axial stability. No wound leakage was seen even without any sutures. The mean BCVA was 0.48 logarithm of the minimum angle of resolution (logMAR) units preoperatively and 0.17 logMAR units at 3 months postoperatively (P = 0.003). The mean corneal endothelial cell loss was 6.0±7.3% (P = 0.63) at 3 months. The mean IOL tilt was 2.3±1.9°. The postoperative complications included iris capture by the IOL in 3 eyes (8.6%), ocular hypertension in 2 (5.7%), and cystoid macular edema in 1 (2.9%). There was no postoperative retinal detachment, endophthalmitis, IOL dislocation, or vitreous hemorrhage.

CONCLUSIONS

The 27-gauge needle-guided intrascleral posterior chamber IOL implantation technique provides good IOL fixation with reliable wound closure without the use of any sutures. We recommend this technique for secondary IOL implantation.

Simplified ab externo scleral fixation for late in-the-bag intraocular lens dislocation

Many surgical techniques to repair late in-the-bag intraocular lens (IOL) dislocation have been described. We present a modification to ab externo scleral fixation of in-the-bag IOL dislocation that minimizes cumbersome intraocular manipulations. Using an iris hook for intraocular suture retrieval under direct visualization eliminates the need to mate the suture needle with a hypodermic needle, and the site through which the hook is used provides an ideal place for suture knot burial, potentially minimizing late suture erosion or exposure.

Single-suture scleral fixation of subluxated foldable intraocular lenses

PURPOSE

To evaluate the results of single-suture scleral fixation of subluxated foldable intraocular lenses (IOL) in eyes with sufficient residual capsular support.

METHODS

The results of IOL repositioning by single-suture scleral fixation in 6 eyes of 6 patients with IOL subluxation were included. All subluxated IOLs were single-piece hydrophilic acrylic. Subluxation resulted from posterior capsule tears in 3 eyes, zonular dialyses in 2 eyes, and zonular dialysis with a capsulorhexis tear in 1 eye. A similar technique was used in all eyes in which one haptic was externalized through a superior clear corneal incision and tied with a Pair-PAK 10-0 polypropylene suture, and was finally retracted and fixated behind the iris close to the ciliary sulcus at the 12:00 meridian. All patients were followed up for at least 6 months.

RESULTS

Best-corrected visual acuities ranged between finger counting and 20/70 (mean logMAR 1.02±0.64) preoperatively, and between 20/100 and 20/20 (mean logMAR 0.22±0.26) at the final postoperative visit. All IOLs remained centered and no significant postoperative complications were encountered except for an IOL tilt which resulted in a considerable oblique astigmatism in one eye.

CONCLUSIONS

Subluxated foldable IOLs may safely be repositioned and secured with a single scleral fixation suture in selected cases with adequate amount of capsular remnants.

Clinical comparison of ciliary sulcus and pars plana locations for posterior chamber intraocular lens transscleral fixation

PURPOSE

To compare the clinical outcomes of transscleral fixation of a posterior chamber intraocular lens (PC IOL) in the ciliary sulcus or pars plana.

SETTING

Department of Ophthalmology, Seoul National University College of Medicine, Seoul, South Korea.

DESIGN

Comparative case series.

METHODS

This retrospective chart review comprised eyes having ciliary sulcus or pars plana fixation of a 3-piece foldable acrylic PC IOL between January 2003 and August 2010. The postoperative corrected distance visual acuity (CDVA), efficacy index, safety index, endothelial cell count (ECC), and complication rates in the 2 groups were compared.

RESULTS

The ciliary sulcus group comprised 38 eyes and the pars plana group, 56 eyes. There was no significant between-group difference in the postoperative CDVA, efficacy index, safety index, or ECC. The mean spherical equivalent difference was larger in the ciliary sulcus group. Intraocular lens dislocation and pupillary capture of the IOL optic occurred more frequently in the ciliary sulcus group (P=.001 and P=.041, respectively). However, retinal detachment, IOL decentration or tilt, cystoid macular edema, secondary glaucoma, and vitreous hemorrhage did not differ significantly between the 2 groups.

CONCLUSION

The pars plana location for PC IOL transscleral fixation was as safe and effective as the ciliary sulcus location.

Intraocular lens exchange through a 3.2-mm corneal incision for opacified intraocular lenses

Aim:

The aim was to evaluate visual and refractive results and complications of intraocular lens (IOL) exchange through a 3.2 mm corneal incision for opacified IOLs.

Materials and Methods:

This retrospective study comprised 33 eyes of 32 patients with IOL opacification requiring an IOL exchange between July 2003 and March 2007. Exchange surgery was performed through a 3.2-mm temporal clear corneal incision followed by implantation of a new foldable hydrophobic IOL. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), topographical astigmatism, and refractive cylinder were evaluated. Surgically induced astigmatism (SIA) was calculated and complications were recorded.

Results:

Opacification was observed in 25 eyes (76%) with Aqua-Sense, 3 eyes (9%) with Hydroview, 3 eyes (9%) with MemoryLens IOLs, and 2 eyes (6%) with DgR. The mean follow-up period was 36.54 months. An uneventful IOL exchange was achieved in 18 eyes (55%). Zonular dehiscence occurred in 9 eyes (27%), and posterior capsule tear developed in 4 eyes (12%). The mean preoperative BSCVA (mean ± standard deviation, decimal scale) was 0.13 ± 0.08 (mean: 20/150, range 20/2000 to 20/60) and improved to 0.63 ± 0.18 (mean: 20/32, range 20/60 to 20/20, P < 0.001). The mean SIA was 0.70 D. Seven eyes (21%) had 0.5 D or lower SIA.

Conclusion:

IOL exchange is a technically challenging procedure with potential risks of reversing the advantages of a prior small-incision cataract surgery. The use of a small corneal incision for IOL exchange could preserve the advantages of modern phacoemulsification surgery with acceptable SIA related to the procedure.

Modified transscleral fixation using combined temporary haptic externalization and injector intraocular lens implantation

Several transscleral suturing techniques require intricate surgical maneuvers and are associated with an increased risk for surgical trauma. We describe a new scleral fixation method that combines the advantages of temporary haptic externalization and injector implantation of an intraocular lens (IOL). After IOL insertion with the injector, each haptic is externalized through 2 adjacent corneal incisions. A 10-0 polypropylene suture loop is made at each exposed haptic and transscleral IOL fixation performed. This modified technique is a safe and effective way to fixate the IOL in eyes with insufficient capsule support.

Ab externo direct suture technique for dislocated intraocular lens

We describe a scleral fixation technique that uses an ab externo direct suture through the eyelet of a dislocated intraocular lens (IOL). This modified technique may provide an easy and effective way to reposition a dislocated posterior chamber IOL.

Ab externo scleral suture loop fixation for posterior chamber intraocular lens decentration: clinical results

PURPOSE

To evaluate the efficacy and safety of an ab externo suture retrieval and scleral fixation technique in the treatment of subluxated posterior chamber intraocular lenses (PC IOLs).

SETTING

Academic tertiary care centers.

METHODS

Surgical databases from 2 surgeons were reviewed for consecutive cases from March 2000 to April 2004 in which the ab externo scleral suture fixation technique was used and a minimum follow-up of 3 months was completed. Patient charts were reviewed for 15 eyes that had decentered in-the-bag PC IOLs, 12 eyes with subluxated sulcus or bag-sulcus positioned PC IOLs, and 3 eyes with PC IOLs dislocated into the vitreous.

RESULTS

The mean time from cataract extraction to PC IOL stabilization was 3.4 years (range 2 days to 10.9 years). Surgical repositioning was successfully performed in all patients. After a mean follow-up of 14.7 months, the mean best corrected visual acuity (BCVA) improved from 20/140 to 20/40 (P = .0001). All patients had stable or improved BCVA. All patients with a successfully completed procedure achieved an adequately centered PC IOL postoperatively. One patient (3.3%) developed a significant intraoperative vitreous hemorrhage requiring the procedure to be aborted, but reoperation 3 months later was successful. Postoperative complications included persistent elevated intraocular pressure in 2 eyes (6.7%) and chronic cystoid macular edema in 1 eye (3.3%) that resolved with medication.

CONCLUSION

The ab externo suture loop retrieval and scleral fixation technique was effective in repositioning decentered, subluxated, or dislocated PC IOLs with excellent visual outcomes.

Two-string technique to manage dislocated posterior chamber plate-haptic intraocular lens

We describe a technique for repositioning and transscleral fixation of a dislocated plate-haptic foldable collamer posterior chamber intraocular lens (PC IOL). The displaced IOL was positioned in the anterior chamber, and a double-armed suture on a curved needle was fixed to the sclera at 10:30 o'clock. The needle then entered the globe and passed through the superior haptic eyelet of the IOL. Both were withdrawn through the scleral wound on the opposite side. The inferior haptic was fixed at 4:30 and 7:30 o'clock and provided the mirror reflection of the suture path of the upper fixed haptic. This technique may be a useful alternative to lens removal or exchange.

Late in-the-bag intraocular lens dislocation: Incidence, prevention, and management

Dislocation of an intraocular lens (IOL) with the capsular bag is a late complication of cataract surgery, reported with increasing frequency in recent years. Pseudoexfoliation, uveitis, myopia, and other diseases associated with progressive zonular weakening and capsular contraction are the predisposing conditions. Capsular tension rings probably help but do not prevent this complication. Management includes IOL exchange, replacement with an anterior or a sutured posterior chamber IOL, or suturing the IOL through the bag to the iris or the sclera.